Depression and antidepressants - have psychiatrists got it all wrong?

A recent book about
depression, "Lost Connections: Uncovering The Real Causes of Depression –
and the Unexpected Solutions" by Johann Hari has created quite a
stir. The book has been reproduced in
part in the Guardian newspaper. Johann
Hari repeats a number of views about antidepressant, for example that they only
work by a 'placebo effect' and that they are based on an erroneous view of
depression being due to a 'chemical imbalance' in the brain namely low levels
of serotonin. Hari points out that there
are many social situations that can lead to depression (e.g. death of a loved
one, work related stress). He argues
that we should be focusing on addressing these situations rather than giving
antidepressants to people.

I strongly disagree with
Hari's reading of the literature around antidepressants. The evidence does NOT support the notion that
they only work via a 'placebo effect'.
There is clear evidence that they can work and have a very significant
positive effect on the lives of people who are depressed. I agree that depression is NOT simply due to
a chemical imbalance in the brain.
However there is strong evidence of biological changes in the brain of
people who are depressed. I think it is
also important to consider that "depression" is probably not just one
thing. At one end of a severity spectrum
there is simply human misery which is part and parcel of everyday life. At the other end there is a disorder in which
people can experience hallucinations and delusions, stop eating and drinking
and have intense suicidal ideas and planning.
Part of the reason why there seem to be endless debates about what
depression is and how it should be treated is that these very different
situations are conflated. Those arguing
most vociferously for the use of antidepressants would never suggest that they
should be used for anybody suffering any degree of sadness in any
situation. In addition, the problems
underlying these difficulties, at both ends of the spectrum, are not likely to
be the same for all individuals.
Problems need to be considered at a social (e.g. work stress),
psychological (e.g. loss of a loved one) and biological (e.g. altered
serotonergic neurotransmission) level to be best understood and managed. I agree with an argument that suggests that
it is wrong to just consider depression as a result of a brain dysfunction
ignoring all other factors in a person's life.
However, this is not what good doctors, psychiatrists and mental health
workers are trained to do. They take
into account all aspects of the individual in a holistic way. This should allow for the appropriate use of
medication alongside psychological therapies and social interventions. In my view, a narrow focus just on the social
or psychological factors underlying a person's depression, but ignoring the
biology, is just as bad as an approach that focuses just on the biology and
ignores the circumstances of a person's life.
This is because it potentially leads to the preclusion of treatments
known to be effective.